Podcast Summary: Diabetes Core Update

Special Edition: Diabetes is Primary 2014 Part 3 – Insulin Management

Date: August 7, 2014
Host(s): Dr. Neil Skolnik, Dr. John J. Russell
Guest: Dr. Eric Johnson, University of North Dakota School of Medicine

Episode Overview

This special edition of Diabetes Core Update focuses on insulin management in type 2 diabetes, featuring highlights from Dr. Eric Johnson’s ADA Scientific Sessions presentation. The episode offers practical, up-to-date clinical guidance on initiating and optimizing insulin therapy for adults with type 2 diabetes, barriers encountered in practice, myths about insulin, and effective strategies to maximize patient acceptance and safety.

Key Discussion Points & Insights

1. When to Initiate Insulin in Type 2 Diabetes

• Dr. Johnson emphasizes that nearly all people with type 2 diabetes will eventually need insulin due to progressive beta-cell decline ([01:29]).

• Insulin should be considered when A1C is above target (generally >8–8.5%) or after about five years of diabetes duration as endogenous insulin production wanes.

• Certain clinical scenarios (e.g., significant hyperglycemia, renal impairment, cost concerns) may prompt earlier use.

  “If they live long enough, all of them are going to need an insulin product at some point... quite often our consideration comes when the person's A1C is elevated, quite often when they get beyond eight or eight and a half or not meeting their appropriate target.”
  — Dr. Eric Johnson [01:29]

2. Positioning Insulin in Treatment Algorithms

• The ADA and AACE algorithms both recognize insulin as a valid second-line (after metformin) or subsequent agent.

• In severe hyperglycemia, insulin can be first-line ([02:06]).

  “Shows insulin as possibly a second line agent in some persons with type 2 diabetes and certainly can be considered for a third or fourth line treatment as well.”
  — Dr. Eric Johnson [02:06]

3. Choosing Insulin as Second-Line Therapy

• Insulin preferred when:

  • A1C is significantly above target
  • Oral/injectable options are limited due to renal disease
  • Cost is a concern (basal insulins often less expensive) ([02:50])

  “Basal insulin may be the most cost-effective approach, but it's certainly a good potent choice for some persons as a second-line agent.”
  — Dr. Eric Johnson [02:50]

4. Adjusting Other Medications when Starting Insulin

• Dose reductions in sulfonylureas may be needed to reduce hypoglycemia risk.

• Consider adjusting thiazolidinedione (TZD) doses to avoid weight gain or edema.

• Non-insulin injectables (GLP-1s) may also warrant dose changes ([03:40]).

  “Particularly in the case of sulfonyureas, we may want to decrease the dose…to limit the possibility of hypoglycemia...”
  — Dr. Eric Johnson [03:40]

5. Initial Insulin Strategies & Titration

• Focus on patient confidence and comfort with modern insulins, especially pen devices.

• Start with 10 units of basal insulin daily, titrate by 3 units every 3–5 days; goal fasting blood sugar individualized (e.g., <110–140) ([04:27]).

• Alternatively, a weight-based dose can be used, but simplicity often key.

  “Quite often you can start at 10 units daily with a basal insulin and then increase that, perhaps three units every three to five days...”
  — Dr. Eric Johnson [04:27]

6. Patient & Provider Barriers to Insulin Initiation

• Emotional barriers from past negative perceptions; providers should confidently communicate advantages of modern insulin and ease of pens ([06:04]).

• Historic linkage of insulin initiation with complications (e.g., amputations) is a misconception stemming from delayed therapy in the past ([06:52]).

  “I have patients who will tell me I had an older relative...on an insulin product 15 or 20 years ago. They didn’t do well with it. So I want to contrast that with a more modern product...”
  — Dr. Eric Johnson [06:04]

7. Common Pitfalls in Insulin Management

• Failure to provide clear titration schedules results in inertia ([07:33]).

• Need for frequent patient follow-up or written algorithms.

• Splitting basal insulin unnecessarily in most cases—better alternatives exist (additional mealtime insulin or GLP-1 agonists) ([07:33], [08:43]).

  “Person will be started on 10 units or some weight based dose and then nothing happens until the next appointment...I think most patients, if we give them written directions for a titration algorithm, they're going to be able to handle that...”
  — Dr. Eric Johnson [07:33]

8. Optimizing Dual Therapy or Stepwise Intensification

• For escalating doses of basal insulin, instead of splitting doses, add GLP-1 or a bolus of rapid-acting insulin before the largest meal ([08:43]).

• Postprandial glucose becomes a bigger contributor to elevated A1C as patients approach target values ([09:16]).

  “If I get to the maximum dose of a pen...maybe it's time for me to be thinking about adding mealtime insulin...”
  — Dr. Eric Johnson [11:07]

9. Educating on Glucose Monitoring

• Don’t over-burden patients; recommend strategic, variable self-monitoring (e.g., rotate times of checks, include postprandial readings if on mealtime insulin) ([09:41]).

• “More data, less pain” approach for actionable results.

  “Maybe rotate those around, not just be focused on morning and evening. Maybe try to do some in the middle of the day or maybe two hours after a large meal...”
  — Dr. Eric Johnson [09:41]

10. Preventing Hypoglycemia and Quality of Life Considerations

• Avoid “over-basalizing”—if high doses of basal insulin needed, consider adding GLP-1 or mealtime insulin.

• Be mindful of hypoglycemia risks; tailored regimens for individual quality of life ([11:07]).

  “If we don't over basalinize our patients, we're less likely to have issues with hypoglycemia...”
  — Dr. Eric Johnson [11:07]

Memorable Quotes

• On patient perceptions:
  “We need to be pretty matter of fact about this. We need to talk about how modern insulin products are much safer.”
  — Dr. Eric Johnson [06:04]

• On titration and patient empowerment:
  “…it gives [patients] a lot of control to incrementally get toward their goal.”
  — Dr. John J. Russell [05:36]

• On addressing misconceptions:
  “That’s often because people have waited too long until they start more aggressive management.”
  — Dr. John J. Russell [06:52]

Timestamps for Key Segments

• Introduction & Guest Welcome: [00:11–01:17]
• When to Consider Insulin: [01:29–01:58]
• Insulin in Treatment Algorithms: [02:06–02:45]
• Insulin as Second-Line Therapy: [02:50–03:28]
• Adjusting Other Agents: [03:40–04:17]
• Starting & Titrating Insulin: [04:27–05:36]
• Barriers to Initiation: [06:04–06:52]
• Pitfalls in Insulin Management: [07:33–08:38]
• Alternative Intensification Strategies: [08:43–09:16]
• Glucose Monitoring Advice: [09:41–10:36]
• Hypoglycemia, Quality of Life, and Over-Basalization: [11:07–11:58]
• Conclusion: [12:17–12:20]

Summary Tone & Clinical Relevance

The episode maintains a practical, reassuring, and evidence-focused tone, emphasizing patient empowerment, simple protocols, and the importance of dispelling outdated fears about insulin. Effective insulin management requires both clear provider guidance and individualized patient education—core messages of both Dr. Johnson and the hosts.

For more primary care diabetes guidance and evidence reviews, visit:
www.diabetesjournals.org